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Continue on the back if necessary What could have been done to prevent this injury/near miss What parts of your body were injured If a near miss how could you have been hurt Did you see a doctor about this injury/illness If yes whom did you see Doctor s phone number Date Has this part of your body been injured before If yes when Time Your signature Supervisor s Accident Investigation Form Name of Injured Person Date of Birth Telephone Number Address City Circle one Male State Zip Female What...
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Yes No Please describe the hazard. * If yes, tell a supervisor: * How do you feel? * How does the incident affect you? Why did the incident happen? Please answer the following questions: How was the incident? Did you notice the hazard? When and where was the incident? Did you know or should you have known about the hazard? Who else in the process room/facilities handled the incident? Please describe how all hazardous situations are managed? What steps does the Hazardous Conditions Review Committee (HCRCC) take in response to your report? Do you know of any other incidents in which this hazard may have caused injuries ? Please describe the hazard. * If yes, tell a supervisor. * Other Workplace Hazards or Problems Please report these incidents: * Is there any information you have about the hazard? (For example, information on how to recognize the hazard and proper handling) Please describe the hazard. * If yes, tell a supervisor. * Have you previously informed your supervisor of the hazard? Are you aware of similar hazards in other facilities, such as electrical wiring, flammable liquids, or other combustible materials? * How does your condition change since you reported it? Explain what you see (for example, you are unable to use equipment for any reason) and how your condition is affecting you. Please summarize the hazards identified and describe how they would normally be handled. To be safe, please follow these tips Inspect all equipment, structures, and related facilities before entering or working in them. The HCRCC conducts hazard assessments to monitor and evaluate hazards that require attention by all employees in the facility (not just you). This means that all employees must use or have access to protective equipment whenever they enter these facilities. All HCRCC visits are conducted by trained hazardous materials teams. The purpose of these visits is to inspect areas for flammable liquids. This does not necessarily include any chemical, biological, or nuclear (CBBN) safety aspects of these locations. A good HCRCC visit checklist is available at our Web site (www.hs-ps.gc.ca). Please complete this checklist prior to the interview and have it completed when you report any incident to the HCRCC. You will be able to obtain the checklist from each HCRCC office. The checklist will be available for download during the interview. Before reporting any incident, ensure: There is a HCRCC representative there; Your supervisor understands the nature
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